INFECTIOUS ICTERUS The occurrence of widespread infectious jaundice, epidemic in type has been repeatedly noted in early life. Sporadic eases are less fre quent. This fact alone goes to prove the infectious nature of jaundice, oecurring at this time of life. Epidemics have been reported from many different countries and I have at my command considerable data concerning those which broke out in Switzerland.
The city of Berne has been afflicted with various mild epidemics of jaundice. This was especially noticeable at the time of an epidemic cf typhoid fever (from which disease Berne is usually free) which was due to infection of the water supply (18981. 1 have also notes on small household epidemics where several children of one family were taken sick one after another with a febrile jaundice, associated with swelling of the liver and spleen. Beatenberg was visited with an epidemic of jaundice in MS. Within three months fifty children who all went to the sante school were taken sick. Three other schools escaped infection. A similar epidemic occurred in Cressier in Freiburg in the same year. Nearly all the children attending school were successively attacked. A general inquiry- among Swiss physicians showed that there had been several small epidemics of infectious jaundice in that year and that in former years also the disease had been wide-spread, attacking princi pally the children. We must therefore admit then that jaundice in epidemic form is by no means infrequent in childhood.
The source of the infection cannot as a rule be determined; the physicians of Beatenberg could find no definite cause for the outbreak; the water supply was good, the weather warn) and dry, and there had been no gross errors in diet. So many cases of infectious jaundice developed in Saxony (1868 to 1889) that they constituted a genuine epi demic, for which Meinert could find no cause. The simultaneous occur rence of so many cases in Switzerland in the year 1898 would seem to show that atmospheric conditions played some part in the causation of the disease. The effect of improper food in causing jaundice is illustrated by the following history of a family in Mettmenstetten (Switzerland) where six children were taken ill with jaundice almost at the same time.
The father who kept many bees had prescribed a honey cure for the children, which resulted after several weeks in digestive disturb ances and jaundice. The children recovered promptly when the honey cure was discontinued. Two months later the honey cure was again begun; jaundice followed in three weeks time.
Most cases occur in children over three years of age. Younger children are also infected. In the Zurich home for rachitis at 2Egeri within six weeks time four children from one to two years of age became jaundiced (1891). The febrile manifestations lasted front eight to ten days.
The onset and course of this disease are like one of the infections. The onset is usually sudden with fever, vague general pains and chills or vomiting. The stools may be loose or there may
be constipation. Some epidemics may- begin with angina, in others bronchitis is a constant feature. The yellowish discoloration of the skin and the mucous membranes usually appears on the second day, associated with other physical signs of jaundice. The liver is usually considerably enlarged, sensitive to pressure, as is also the spleen. In -older children the pulse may be slow. This is not usually the ease with the younger ones. A trace of albumin is usually found in the urine. The yellowish color of the skin is often only indicated, but may be very intense a few hours after the onset of the disease. The fever generally disappears after a few days and the children make a prompt recovery. The jaundice also goes quickly in most cases. Occasionally we meet with protracted cases.
The disease usually runs a favorable course in our country (Switz erland); elsewhere the results have not been so favorable. Out of five hundred and eighteen eases thirteen died (Meinert), two of whom presented the picture of acute atrophy of the liver. Kissel had six fatal results out of 911 cases. Towards the end of the disease severe nervous symptoms (convulsions, loss of consciousness, coma) appeared, resembling chohemia.
This type of the disease is closely related to Weirs Disease (icterus gravis) which must also be considered an infectious jaundice. In this disease, besides the high fever and marked nervous symptoms am often encountered hminorrhages under the skin and mucous membranes. Adults are more frequently attacked by this disease.
Jaeger identified the bacillus proteus fluorescens as the etiological factor in a severe type of this disease. Whether proteus species directly invade the liver and the bile-passages, Or whether they act through their toxines in the milder forms of Weil's disease, remains yet to be determined; so also is the part played by other micro-organisms (bacillus coli, ete.).
Attempts to agglutinate typhoid bacilli (Grunbaum, Zupnick, and others), the paratyphoid bacilli (Netter), with icteric serum have shown that icterie serum usually agglutinated more strongly than normal serum. Langer (Prague) obtained negative results in 14 cases, using Ficker's method of diagnosis.
Our prognosis must be made with care in infectious jaundice, though as a rule the disease terminates favorably in childhood.
Treatment is prinicipally dietetic. Fatty foods must be especially avoided and rice, barley or oatmeal gruel given freely, besides milk diluted with tea. In the latter stage of the disease wheat bread, white meat and preserves may be allowed. Constipation must be prevented and rhubarb is of service; but in some cases intestinal irrigation inay be of decided help. Hydrochloric acid in small doses is valuable for its tonic effect. Should diarrhma be marked and the stools become offensive, small doses of salol 0.25-0.5 Gm. (4-8 gr.) four times a day will be of service.